|Effective Communications for Nutrition in Primary Health Care (UNU, 1988, 208 pages)|
Population and Community Development Association (PDA), Bangkok, Thailand
By the early 1970s, Thailand's population had increased to an alarming level, with a growth rate that indicated that the population would double by the end of the century.
Organized family planning programmes were producing marginal results and it became clear that a new systematic and concerted effort was needed to motivate the public. New and innovative approaches were needed, and with this in mind the author launched a nationwide social marketing campaign designed to introduce and/or reintroduce family planning, operating through the newly created Community-based Family Planning Services (CBFPS), a major bureau of the Population and Community Development Association (PDA).
In a systematic fashion, the social marketing programme desensitized the population to the traditionally sensitive issue of family planning, demonstrated the need for family planning, and motivated people to use contraceptives that were provided through community-based voluntary distributors. Using local channels for communicating the family-planning message, the programme was conducted in an atmosphere that reflected its insight into Thai culture.
This paper will present a basic framework for a social marketing programme, and as an illustration will relate its various components to PDA's own experiences in contraceptive and family-planning social marketing. It is hoped that this framework will be of assistance in the design of social marketing or communication programmes in other areas of health, such as nutrition. The framework consists of four sections: social preparation, communications, distribution/service provision, and reinforcement/expansion.
SOCIAL RESEARCH AND PREPARATION
Define Outcome Desired
It is imperative that the specific outcome and changes in behaviour desired in the target population are clearly defined. Attention to the final outcome(s) will focus the direction of the social marketing programme and serve as a reference for evaluation. It will also provide guidance for the appropriate modification of the programme.
For a family-planning programme, the ultimate goal is reducing the population growth rate. The specific action-oriented result desired is the use of contraceptives. With this firmly in mind, PDA's programme was not distracted by its success in such steps as providing knowledge and making contraceptives available. With the goal clearly defined the steps are perceived in their proper perspective as prerequisites to the desired outcome.
Analysis of Target Population
Because social marketing programmes seek to modify existing behaviour, or encourage new practices, an understanding of the existing baseline behaviour is necessary before a social marketing programme can be appropriately designed.
It is of vital importance to know whom the programme is trying to reach and what the constraints affecting health practices are. Particular attention should be paid to those factors that impede or facilitate the desired behaviour: Is knowledge lacking, are there accessibility problems, are there economic difficulties or social/cultural barriers?
For example, through the social research process it was found that the Thai population first needed to be desensitized to the very issue of family planning. People were afraid to talk about family planning and were embarrassed to buy contraceptives. Therefore, one of the prerequisite behaviours necessary to achieve the ultimate desired outcome was for the target population to be able to talk openly and handle contraceptives as normal household items. It was not until this had been achieved that the next steps in the programme could be taken.
Determining what motivates the target population to carry out the desired behaviour, as well as what it considers to be rewarding, is an essential part of background research. Rewards may include social rewards such as praise, recognition, or attention (possibly through publicity), tangible rewards such as food or prizes, or behavioural rewards such as engaging in enjoyable activities. An illustration of how knowledge of the target population was used in PDA's social marketing programme is reflected in the following example.
It was realized that vasectomy services were not available in the villages and that some form of motivation was also needed to spur people to final action. With these two facts in mind, PDA developed a system whereby, if 15 men in a village wished to have a vasectomy, PDA would pick them up in a bus and drive them to PDA's clinic in Bangkok. After having vasectomies, they were given a tour of Bangkok, many visiting it for the first time, and were taken to the holiest of all places for Thai Buddhists, the temple of the Emerald Buddha.
Social preparation includes those activities that are conducted prior to either the implementation of services or the commencement of a directed communication programme, and that serve to increase the programme's acceptability and credibility.
Social preparation activities usually involve visits to government officials, village headmen, village committees, monks, and any other individuals or groups whose interests are involved. During such visits, the goals and objectives of the programme are explained and support is sought. The basic objectives of social preparation are to: (a) establish a trusting relationship with the community; (b) gain official recognition through political and religious support; and (c) create a favourable environment for a communication programme and for the desired action to take place.
The following steps are felt to be essential components of any effective communication programme. Some steps may occur simultaneously or in a different order from that presented. They have been separated only to clarify the process involved.
Choice of Media
Mass media, while able to relay knowledge and information, have rarely had lasting effects as regards changes in behaviour. PDA's decision to use individuals to communicate family-planning messages was made for the following reasons: (a) they are able to attract people's attention; (b) they can respond to local conditions; (c) they have a greater capacity for convincing people than have mass media; (d) they can generate a rapport with the target group and develop a trusting relationship; (e) the two-way communication made possible helps ensure that family-planning messages are correctly understood.
Mass media, however, were used extensively to communicate family-planning messages indirectly by carrying news stories on PDA's promotion activities. These family planning promotional events not only caught the attention of the target population, but also of the news media as well. Such events included: releasing hundreds of helium-filled balloons to which were attached cards entitling the finder to a free vasectomy; special Vasectomy Carnivals that included condom-blowing contests, performances by local dramatic troupes extolling the advantages of practicing family planning, and feature-film shows with family-planning messages presented during the breaks; school assembly meetings during which children recited family-planning nursery rhymes, sang family-planning songs, and had condom-blowing competitions.
Mass media were also used to inform the population where services were available.
At the beginning of PDA's contraceptive social marketing campaign, individual communicators/motivators presented family-planning messages to large audiences at mass meetings held for such groups as teachers, policemen, factory workers, and government employees. These gatherings were light-hearted, with a carnival-like atmosphere designed to make people laugh at what was traditionally a sensitive issue. When services were being instituted in villages, similar village-wide meetings were organized to inform and motivate people to action.
After community-based services had been established in a particular village, the voluntary distributor assumed the responsibility for communicating family-planning messages and for motivating individuals to use contraceptives. These activities were usually carried out on a person-to-person basis. By using local and well-respected people from communities as distributors and communicators, family-planning messages were adapted to meet local conditions and were more readily accepted.
Gaining and Maintaining the Target Population's Attention
The key to gaining and maintaining attention is to know the target group and to appeal to their interests using active involvement, action, colour, and a sense of fun; this requires the use of imaginative and varying approaches.
PDA's social marketing communication programme made use of gimmicks, prizes and humour to catch people's attention. Promotional T-shirts were produced with slogans such as: Life Begins with Family Planning," and "Many Children Make You Poor." Plastic-encased condoms, on which was written: "In case of emergency, break glass." were distributed for use as key chains. Condom-blowing contests made people laugh and held their attention so that family-planning messages could be delivered.
Removing Obstacles to Communication
In a social marketing communication programme obstacles may be physical, economic, environmental. or social. The predominant barrier to establishing an effective family-planning programme in Thailand was the Thai people's traditional avoidance of discussing human reproductive physiology and their sensitivity to the issue of family planning. Contraceptives were considered "dirty" and so the PDA's social marketing spearhead was a desensitization campaign designed to show people that family planning was only as dirty as people's minds made it. A personal and direct approach was used: actually putting condoms in people's hands so that they could see for themselves and having people then blow them up in condom-blowing competitions. One minute people were self-conscious and the next they were laughing in the realization that family planning was not something strange or mysterious at all. Once people were desensitized, it was possible to communicate and discuss family-planning issues. The Thais proved to be very ready to listen when problems were presented in a clear, concise, and simple manner.
Establishing How the Problem Relates to the Individual
In PDA's family-planning programme, people needed to be made aware of the rapidly increasing population. Not all people, even among government officials, felt that a rapidly increasing population posed a problem.
Messages on population growth were given as clear facts, such as that the population of Thailand would double by the end of the century if its growth rate were not reduced. This was shown graphically by posters and T-shirts depicting an earth so crowded that people were falling off.
Unless people feel that problems relate to them directly and personally, it is unlikely that they will be motivated to action. The slogan "Many Children Make You Poor," as well as being clear and simple, related the population issue to the individual. The advantages of raising two children well (i.e. being able to provide good nutrition and education) rather than raising many children under deprived conditions were pointed out.
Demonstrating the Need for Action
In conjunction with presenting problems and their relationship to the individual, it is important to foster a perception of the serious consequences should one fail to act.
In promotion family planning, people were made aware of the immediate results of having "too many" children in their family and also the serious problems that would result on a national level from uncontrolled population growth.
Action an Individual May Take
For a family-planning social marketing programme, the required action is clear: use contraceptives. People were therefore informed of the various types of contraceptives available as well as where they could be obtained.
Convincing People that the Suggested Actions Will Be Effective
Particularly with new concepts, individuals are not willing to risk their time, money, security, or health if they are not convinced of the efficacy of the proposed action. Positive statements by well-knwon community members add credibility, and once individuals take action their affirmation of the effectiveness of that action reinforces support of the programme. Proper education must be given so that action is carried out in the proper manner, thus ensuring that the anticipated outcome is achieved.
PDA's approach of first gaining the support of local institutions and officials through its social preparation phase helps to establish the credibility of the programme and of the action that it advocates. A trusting relationship was more easily established by associating the offered services with the village temple. Thus, when a new shipment of contraceptives arrives in a village it is not uncommon for the monk to bless them. Promotional meetings and mobile vasectomy programmes are also held at the temples.
Removing Obstacles to Action
Obstacles to action may be environmental, logistical, social, or economic. Whereas the logistical and economic difficulties may be minimized through an appropriately designed distribution network incorporating alternate financing schemes, the communication programme can be designed to reduce social or cultural barriers.
As previously mentioned, it was necessary to desensitize the Thai population to family planning as a prerequisite to soliciting the desired action. Other obstacles often arose through misinformation spread by rumours. Steps taken to minimize rumours include anticipating them and counteracting or exposing misinformation through education. The target population must be made aware of the secondary effects of their choice of action, and for family planning this includes giving a full description of the side-effects of certain contraceptives. In this way the sources of many rumours are removed.
For social marketing programmes where the desired outcome is the use of a product or service, it must be presented to the potential user in such a way that the products or services are readily available and acceptable. There are many factors to consider in the delivery of goods or services, and these have been well described and analysed in numerous commercial marketing texts.
To increase the acceptability of contraceptives, PDA used community-based volunteers who worked as distributors and communicators. As they were respected members of the community, they were trusted and in this way the services offered through them were made more acceptable. The social preparation phase of the social marketing programme also served to increase the acceptability of services.
PDA's approach was to make contraceptives as easily available as possible by using local channels.
Distribution points used have included: (a) female boat vendors who sold pills and condoms as well as fruit and vegetables; (b) vending machines making condoms available 24 hours a day; (c) urban taxi drivers; (d) factory nurses; (e) mail order- also a good channel for those too shy to buy condoms from a distributor; (f) pharmacies; (g) family-planning supermarkets set up in bus and train stations; and (h) over 16,000 community-based volunteer distributors.
Sterilizations were conducted either through PDA's Mobile Vasectomy Tour Bus Services or at one of four clinics.
It is PDA's philosophy that services will be valued more highly if something is paid for them. Thus, contraceptives are sold for a nominal amount and the revenue thus generated is used to finance the cost of delivery services. For motivational purposes the distributors also receive a small commission on their sales.
The condoms marketed by PDA under the brand name "Mechai" are packaged in attractive, eye-catching colours reflective of the cheerful promotional campaign that accompanied them. A variety of brands are made available in the belief that individuals like to exercise choice. In this way the user feels that the final decision is his own rather than that he is acting because he has been told to do so.
Similarly, with female oral contraceptives, three brands are offered that are distinguished by colour: white, silver, and gold. Although chemically similar, these brands have different prices so that the consumer is able to make a choice. In this way, if the users are not satisfied with one type, they have the option to "try again" with a different brand rather than simply discontinue the method.
Promotion must be continuous if the message is not to be forgotten. In order to do this on the village level, PDA produces a multi-coloured poster every month and posters are sent to every voluntary distributor for display in his or her village. These posters provide information on issues and subjects of interest to villagers, such as agriculture, appropriate technology, water resource development, and health. The information presented, as well as helping to better the villagers' lives, draws them to read the family-planning messages incorporated into the subject-matter.
The village volunteers are also upgraded through specialized training programmes and some are now working as government health communicators under their village health development programme. At these courses the volunteers learn new communication and motivation techniques in addition to skills related to community development.
REINFORCEMENT AND EXPANSION
The marketing programme does not end once the target population begins to practice the desired behaviour. The behaviour must be reinforced in order to be maintained. It has been found that intermittent reinforcement greatly diminishes the potential extinction of the practice. Because the benefits resulting from the practice of family planning are not immediately tangible, it is crucial that those practicing it are given support and reinforcement from the beginning.
As one benefit of using family planning is an improved economic condition, PDA has used various income-raising activities to reinforce or reward fertility management. The acceptor, by using family planning, demonstrates a willingness to take control over and responsibility for his or her own life, and with this mature attitude people are also more likely to take full advantage of an opportunity for economic betterment. Communication materials can work in conjunction with reinforcement activities so that the original purpose of the programme is not lost through the addition of other services.
Examples of Some Reinforcement Activities, Past and Present
1. Better Market Programme
Family-planning participants are given the opportunity to sell their non-perishable products such as coconuts, pumpkins, silk, and handicrafts to PDA, who, in turn, finds a market for them and arranges transportation. By cutting out the middleman the villagers get at least 30 per cent more for their produce.
2. Pig-raising Programme
Male stud pigs are lent free of charge to families practicing family planning who own one or more sows. The resulting piglets are fed on the families' domestic scraps for eight to nine months, during which time the family promises to continue using their method of contraception. PDA then assists in marketing the pigs with the sales profit given to the family.
Supporting communications: Stud pigs used in the programme bear family-planning slogans on their flanks; T-shirts are designed with the message "Let Your Next Pregnancy Belong to the Pig."
3. Community-based Incentive Programme in Thailand (CBIT)
To increase village-level contraceptive-use prevalence rates, community incentives are introduced through credit co-operatives. Preference for loans is given on the basis of family-planning practice and method. As the village contraceptive prevalence rates increase. PDA increases the size of the loan fund. Currently there are six credit cooperatives in north-east Thailand, three of which are run entirely by women.